Provider First Line Business Practice Location Address:
4041 IBIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-1833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-381-0694
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/30/2025